Wheelchairs Corporate Medical Policy

Transcription

1 Wheelchairs Corporate Medical Policy File name: Wheelchairs File code: UM.DME.14 Origination: 04/09/2007 Last Review: 08/2015 Next Review: 08/2016 Effective Date: 3/1/2016 Description/Summary Use of a wheelchair, may be considered medically necessary for a variety of conditions including, but not limited to congenital or chronic conditions, injury or disease. Functional disabilities requiring use of a wheelchair vary in degree and duration; therefore the nature of the functional disability will determine the need for either rental or purchase. Policy Coding Information Click the links below for attachments, coding tables & instructions. Attachment I- Code Table & Instructions When a service may be considered medically necessary Manually operated wheelchairs: used when patients are unable to walk or weight bear, but have sufficient upper body strength to propel the wheelchair. Power/electrically operated wheelchairs: used when patients are unable to walk or weight bear and have a lack of upper body strength or upper extremity impairment. Manual wheelchairs may be considered medically necessary when: 1. Member has impaired ability to perform one or more mobility related activities of daily living (MRADL), i.e. toileting, bathing, feeding in his/her residence and mobility limitation cannot be resolved by the use of a cane, walker, or crutches. 2. Wheelchair provides therapeutic benefit to the member related to a medical condition or illness AND 3. Wheelchair is prescribed by a physician. Power wheelchairs may be considered medically necessary when all of the following are present: (Purchase only) Page 1 of 6

2 1. Ambulation is impaired, and 1 or more of the following is present: - Mobility-related activities of daily living unable to be completed - Mobility-related activities of daily living unable to be completed independently - Mobility-related activities of daily living unable to be completed safely - Work or instrumental activities of daily living unable to be completed 2. Ambulatory assistive device (eg, cane, crutches, walker, etc.) does not sufficiently resolve mobility deficit. 3. Controls of powered wheelchair can be safely operated. 4. Inability to operate wheelchair manually due to 1 or more of the following: - Absence or deformity of upper extremity - Chronic upper extremity pain or dysfunction from injuries - Upper extremity strength, range of motion, or coordination inadequate 5. Physical layout and surfaces of, and obstacles in, area in which powered wheelchair is to be used permit safe operation of device. 6. Physical therapist has evaluated patient, concurs that powered wheelchair is most appropriate means for improving mobility, and has written evaluation. 7. A manually operated wheelchair is determined to be inadequate to address the member s need for mobility in his/her home We will approve a wheelchair to the extent that it permits the member to achieve basic mobility. Repairs, maintenance, and replacement of eligible DME on an individual consideration basis when necessary to make the equipment usable. BCBSVT reserves the right to determine whether rental or rental to purchase or purchase of the equipment is more cost-effective and/or appropriate. The total rental benefits may not exceed our allowed price for the purchase of equipment. When a service is considered not medically necessary Advanced features such as seat lifts, electronic lifts or special tires are not considered medically necessary. When a service is considered non-covered (benefit exclusion) Motorized scooters are an explicit exclusion and not a covered benefit. Any treatment, Durable Medical Equipment, supplies or accessories intended principally for participation in sports or recreational activities or for personal comfort or convenience. New technology introducing improved features for existing medical equipment. Benefits are considered not medically necessary for "deluxe" features to make the equipment more versatile or easier for the member to use if the standard/conventional equipment meets the member's functional needs. When a wheelchair does not provide a therapeutic benefit to a patient in need because of certain medical conditions or illnesses. Items, add-ons, or upgrades that are intended primarily for member/caregiver convenience, or that do not significantly enhance DME functionality. Page 2 of 6

3 Policy Guidelines For all wheelchair requests (rental or purchase), the following information is required to establish medical necessity: 1. Clinical summary including member s disease process, injury or disability with description of functional impairment 2. Length of time wheelchair will be medically necessary 3. code for wheelchair requested 4. Physician s treatment plan 5. Rental or purchase price In addition, when requesting purchase of a wheelchair, the following information must be provided: 1. Wheelchair evaluation by a physical therapist. 2. Invoice including description, codes and pricing for all components of the wheelchair requested Reference Resources 1. BCBSNC Corporate Medical Policy for wheelchairs DME0250, BCBSMA 2. Wheelchairs: Motorized-Benefit Information 3. MCG Ambulatory Care 19th Edition. Wheelchairs, Powered. A-0353 (AC). Related Policies See Durable Medical Equipment (DME) medical policy. Document Precedence Blue Cross and Blue Shield of Vermont (BCBSVT) Medical Policies are developed to provide clinical guidance and are based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, BCBSVT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract language, the member s contract language takes precedence. Audit Information BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, BCBSVT reserves the right to recoup all non-compliant payments. Page 3 of 6

4 Administrative and Contractual Guidance Benefit Determination Guidance Prior approval is required and benefits are subject to all terms, limitations and conditions of the subscriber contract. Incomplete authorization requests may result in a delay of decision pending submission of missing information. To be considered compete, see policy guidelines above. An approved referral authorization for members of the New England Health Plan (NEHP) is required. A prior approval for Access Blue New England (ABNE) members is required. NEHP/ABNE members may have different benefits for services listed in this policy. To confirm benefits, please contact the customer service department at the member s health plan. Federal Employee Program (FEP) members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. Coverage varies according to the member s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict. If the member receives benefits through a self-funded (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the member s plan documents or contact the customer service department. Policy Implementation/Update information 04/2007 New policy. Reviewed by CAC 07/ /2015 Power wheelchair medical necessity added. Code table updated. Headers updated and clarified. Added benefit exclusion header. Non- specified codes added to PA. Power operated vehicles added to non-covered code table. Moved all other wheelchairs and accessories to only require PA if over dollar threshold depending on group. Health Care Procedure Coding System () codes related to chemotherapy drugs, drugs administered other than oral method, and enteral/parenteral formulas may be subject to National Drug Code (NDC) processing and pricing. The use of NDC on medical claims helps facilitate more accurate payment and better management of drug costs based on what was dispensed and may be required for payment. For more information on BCBSVT requirements for billing of NDC please refer to the provider portal latest news and communications. Eligible providers Qualified healthcare professionals practicing within the scope of their license(s), to include: Page 4 of 6

5 Allopathic Physicians Osteopathic Physicians Durable Medical Equipment Providers Hospitals Approved by BCBSVT Medical Directors Date Approved Joshua Plavin, MD Senior Medical Director Chair, Medical Policy Committee Robert Wheeler MD Chief Medical Officer Attachment I Code Table & Instructions Code Type Number Description Policy Instructions Services are considered medically necessary when applicable criteria outlined in this policy are met. Other wheelchairs and accessories not listed below require prior approval if the purchase price is over $ E1229 Wheelchair, pediatric size, not otherwise specified E1239 K0108 Power wheelchair, pediatric size, not otherwise specified Wheelchair component or accessory, not otherwise specified Prior Approval Required K0898 Power wheelchair, not otherwise classified The following codes will deny because they are contract exclusions E1230 K0800 Power operated vehicle (3- or 4- wheel non-highway), specify brand name and model number Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds Page 5 of 6

6 K0801 K0802 K0806 K0807 K0808 K0812 Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds Power operated vehicle, not otherwise classified Type of Service Place of Service Home Durable medical equipment RLG Page 6 of 6